Friday, March 28, 2014

It's about the patient: the effect of depression and other psychiatric disorders on shoulder arthroplasty outcomes.

The influence of psychiatric comorbidity on perioperative outcomes after shoulder arthroplasty

These authors sought to evaluate the influence of a preoperative diagnosis of depressive disorder, anxiety disorder, schizophrenia, or dementia on in-hospital (1) adverse events, (2) blood transfusion, and (3) nonroutine discharge in patients undergoing shoulder arthroplasty. They used the National Hospital Discharge Survey database, to identify 348,824 discharges having undergone partial or total shoulder arthroplasty from 1990 to 2007. 

They found that one in twelve patients receiving shoulder arthroplasty had some form of mental disorder: depression 4.4%, anxiety disorder, 1.6%; schizophrenia, 0.6%; and dementia, 1.5%. 

Depression, anxiety and dementia were associated with higher rates of adverse events.  Any preoperative psychiatric illness was associated with higher rates of nonroutine discharge.

Comment: We've put up many posts on the 4 Ps, emphasizing the importance of the patient in the outcome of shoulder arthroplasty. Paraphrasing Osler, "it is more important to know what patient the disease has than what disease the patient has".

It is apparent that individuals with emotional and psychiatric disorders can develop shoulder arthritis. It is also apparent that shoulder arthroplasty can improve the comfort, function, and overall well-being of a patient with shoulder arthritis. The questions becomes, should the presence of mental disorders change the indications for and the anticipated outcomes of shoulder arthroplasty?

In a prior post, we've pointed out that individuals with depression are more symptomatic with lesser degrees of radiographic arthritis. This suggests the possibility that surgeons may be urged to operate on arthritis in its earlier stages and may have less optimal outcomes.

Mental illness is an important co-morbidity, just like emphysema or chronic heart failure. Identifying these diagnoses before committing to surgery may help optimize decision making regarding the appropriateness of surgical treatment. In some cases these co-morbidities are modifiable, in which case their treatment should take place before the surgical treatment of arthritis. Adverse events and non routine discharge are costly to the patient and to the payers of health care.


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